Country Mansion

Type of visit: Required - 1 Year

On September 30, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator 1 (A1) John Cendana and explained the purpose of today's visit. The facility is licensed for 4 non-ambulatory and 2 ambulatory residents. There are currently 4 residents who reside at this facility. During the visit, all residents were away from the facility at their day programs. There were 2 staff present. At 9:10AM, LPA conducted record reviews of 4 staff and 4 resident files. Files were observed to contain the required components. Staff files contained updated annual training records. At 9:30AM, LPA conducted a medication administration review. Medications were stored in a locked cabinet. The facility uses a MAR sheet to record all dispensed medication to residents. At 9:40AM, LPA toured the facility with A1. The facility was clean, safe, and in good repair. The living room contained seating to accommodate the current census. A public telephone was available for resident use. The resident bedrooms were in good repair, and furnished with a dresser, lighting, bed, and night stand table. The furniture was observed to be in good repair. Bedroom windows and screens were both in good repair. The resident bedrooms contained clean linen and bedding. 2 out of 4 resident bedrooms contained direct exit doors. The exit doors were free of obstructions. Resident bedrooms contained working smoke detectors in each bedroom ceiling. Facility bathrooms were clean and sanitary. Non-slip mats and grab bars were available to ensure resident safety. Continued on LIC 809-C. The facility contained extra bedding and clean towels. The LPA inspected the staff office and staff room which were observed to be free of hazards. The facility contained at least one week of non-perishable food supply and at least 2 days worth of perishable food items. The facility had a menu posted on the refrigerator. Residents' special diets and food sensitivities were also posted on the refrigerators. The kitchen contained cooking appliances which were observed to be in good working condition. Sharps and toxins were stored in a locked area in the laundry room. The facility contained laundry appliances which were in good working condition. LPA toured the exterior of the facility which was free of hazards. The walkways were free of obstructions. There was a shaded patio area with outdoor furniture available for resident use. The facility temperature was 74 degrees. The hot water temperature was 108 degrees. The fire extinguishers were serviced annually on April 17, 2026. LPA requested the following documents to be mailed/ faxed to the Regional Office within 15 days: - LIC 500 Personnel Report, LIC 308 Designation of Facility Representative, LIC 610E Emergency and Disaster Plan, and a copy of the Liability Insurance Certificate. As a result of this annual inspection, the facility is in compliance with Title 22 Regulations. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 30, 2026

Allegation investigated: Staff hit a resident

On 12/18/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Zoilo (John) Cendana (S2) and explained the purpose of the visit. LPA Tamayo called Administrator, Diana Cendana (S1), and left them a voice message informing them of their presence at the facility and purpose of this visit. The purpose of this visit is to deliver findings and close the complaint investigation of the allegation above. A brief interview conducted with S2. Allegation: Staff hit a resident It was alleged staff hit a resident, based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. According to the SOC 341 dated 10/30/2025, it was reported that on the Resident (R1) stated that "about a week ago", Staff 3 (S3) "told the client to go to bed and slapped her on the forehead, 3-4 times". CONTINUED ON 809-C Unsubstantiated Per record review and interviews, R1 did not recall the date of the incident nor the name of staff person's who hit them but was able to point out S3 to S1. Per LIC 500, there were only two night staff on at that time. S1 reported there were no visible injuries and the client did not complain of any pain for R1. Interviews with three collateral witnesses (P2-P4) and care staff (S1 and S2) informed that R1 has been out of baseline in the past three months and is awaiting psychiatric evaluations. Based on interviews with S1, S2, P1,and P3, R1 has never made allegations of staff hitting them at their day program nor the care home. Additionally, three residents did not corroborate the allegation. S3 declined having ever hit a resident. Per two staff interviews (S1-S2), S3 has not been accused of hitting any other residents in the past. R1 did not respond to interview questions asked by LPA Tamayo on 10/31/25 and 11/7/2025. LTCO (P2) stated R1 did not respond to interview questions on two different attempts. Four out of four facility care staff stated they have not observed staff hit any resident. Interviews with three staff and two residents confirm that the incident was not witnessed. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of staff hit a resident are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the S2, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 27-AS-20251103101720

Type of visit: Case Management - Incident

on 10/29/2025 by Licensing Program Analyst (LPA) Cynthia Tamayo conducted an unannounced case management visit at this facility. This LPA was met by the facility designated Administrator Zoilo (John) Cendana and Diana Cendana who was briefly interviewed at this time. The purpose of this case management visit was to discuss the Unusual Incident Report (SIR) and SOC 341 that were submitted to Community Care Licensing on 10/30/2025. The SIR were submitted into CCL for an incident of suspected abuse of a resident that was reported on 10/29/2025. LPA was present to discuss the background behind the incidents, follow-up by this facility and it's staff, and resident at that time with. There were no deficiencies cited during today's case management visit. Exit Interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 31, 2025

Type of visit: Required - 1 Year

On 10/15/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a required - 1 Year visit. LPA met with care staff Zoilo (John) Cendana (S2) and explained the purpose of the visit. Administrator, Diana Cendana (S1) arrived around 11:45 AM. S2 assisted LPA with annual inspection. An entrance interview was conducted.. The facility is licensed to serve elder adult residents ages 60 and above. Fire clearance is granted for (4) non-ambulatory and (2) bedridden residents. Bedridden to reside in rooms with direct exiting only. LPA observed one staff on shift and one resident present in the facility, as they have a scheduled doctors' appointment. According to facility staff, three out of four residents have gone to their Day Program for the day. LPA toured the physical plant with S2, including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 105.1.*F which was within the required range of 105-120*F. The temperature inside the facility measured at 76*F which was within the required range of 68-85*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date and smoke and carbon monoxide detector(s) in the facility were in good repair. Continued on 809-C The living room area was fully furnished with areas for exercise and lounging. Resident bedrooms were observed to be fully furnished and free from odors. Bathrooms were observed to be clean and fully stocked with hygiene products, a skid mat, and a shower chair. The exterior areas was observed to have areas for outdoor seating, outdoor activities, and gardening activities. No emergency exits were observed to be obstructed. LPA requested resident and staff files for review. LPA reviewed (3) staff files and (4) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following forms were requested to be submitted by 10/22/2025 to Cynthia.tamayo@dss.ca.gov: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance, LIC 9020. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. An exit interview was conducted with S1, and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Oct 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by facility staff, and explained the purpose of the visit. LPA was later met by Administrator Diana Cendana-Keinath. LPA Valerio observed one staff on shift and zero residents present in the facility. According to facility staff, all residents have gone to their Day Program for the day. LPA Valerio and Administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA Valerio inspected the facility kitchen. The kitchen was observed to be clean and organized. The facility was observed to have a minimum supply of two days of perishable food items and a seven day supply of non-perishable food items. All sharps, cleaning supplies, and toxins were observed to be locked and inaccessible to residents in care. Medications were observed to locked at the time of the visit. The living room area was fully furnished with areas for exercise and lounging. Resident bedrooms were observed to be fully furnished and free from odors. Bathrooms were observed to be clean and fully stocked with hygiene products, a skid mat, and a shower chair. The exterior areas was observed to have areas for outdoor seating, outdoor activities, and gardening activities. No emergency exits were observed to be obstructed. LPA Valerio reviewed two (2) resident files and two (2) staff files. LPA observed resident files to be complete with annual documentation. Staff files were up to date with required annual training. LPA requested the following annual documentation be sent to (916) 263 - 4747: LIC 500, LIC 308, LIC 610, Copy of Liability Insurance Per California Code of Regulations (CCR) Title 22 - Division 6, Chapter 8, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2024